Encounter Data Submission FAQs for Medicare-Mediciad …

1 1 Encounter DATA Submission FAQS FOR medicare -MEDICAID PLANS PARTICIPATING IN THE FINANCIAL ALIGNMENT INITIATIVE Updated September 30, 2020 medicare -Medicaid Plans (MMPs) submit Encounter data to CMS for all covered services. Plans submit data to CMS on different files based on whether the covered services are traditionally covered by medicare vs. Medicaid (see Q4 below), and then further, by file type (see Q6 below). Please note that plans submit Prescription Drug Event data for medicare Part D covered prescriptions separately, per standard medicare requirements for those data. Encounter data are critical for evaluation of the demonstrations under the Financial Alignment Initiative (FAI), and to accurately risk adjust medicare payments.

2 This list of frequently asked questions shares lessons learned to date. The CMS MMP Encounter Team (in the medicare -Medicaid Coordination Office [MMCO]) will update the FAQ as we identify additional strategies for improving the timeliness, accuracy, and completeness of MMP Encounter data. New MMPs: Timeframes for Testing, Certification, and Submission of Encounter Data Q1: What is the timeline for Testing and Certification of Systems Access? A: Testing and certification of MMP file structures enable access to the CMS Encounter data Submission system via Palmetto s Customer Service Support Center (CSSC) and may begin as early as 3 months prior to contract effective Q2: Where can I find medicare Medicaid Plan enrollment packets and companion guides?

3 A: Plans can download MMP enrollment packets and companion guides from the Palmetto GBA website under the medicare -Medicaid (FAI) section . All MMPs are to enroll using the provided MMP enrollment packets, regardless of whether the organization has enrolled previously as a medicare Advantage Plan. Q3: How do medicare Medicaid Plans establish connectivity? A: Prior to submitting Encounter data to CMS, MMPs and other entities establish a secure connection to CMS systems. MMPs and other entities use the electronic connection not only to submit data to CMS but also to receive front-end acknowledgement and processing status reports. The Customer Service Support Center (CSSC) works directly with MMPs after they establish connectivity and complete documentation, to ensure plans can complete testing/certification in a timely manner.

4 1 Please see HPMS Memo Timeframes for Testing, Certification, and Submission of Encounter Data by MMPs dated 4/29/2014 " " 2 Submitters complete an Electronic Data Interchange (EDI) Agreement with CMS and submit it to CSSC prior to submitting data. The EDI Agreement is a contract between the MMP or other entity and CMS attesting to the accuracy of the data submitted. An officer ( , CEO) that represents the MMP or other entity must sign this document. In addition, plans need to fill out the Submitter ID Application, and provide an Authorization Letter (if applicable). Prior to submitting production files, anyone submitting Encounter data (the MMP itself or a third party) must complete testing and certification.

5 CSSC coordinates the application process as well as the testing and certification process. MMP Submission Requirements Q4: What are the primary requirements for submitting Encounter data to CMS? A: While MMPs administer an integrated plan, for administrative purposes (including accurate risk adjustment) MMPs distinguish and submit encounters for services primarily covered by medicare on separate files from those benefits traditionally covered by Medicaid. As noted in our HPMS memo of July 26, 20132, however, MMPs have flexibility in establishing a reasonable methodology by which to attribute claims to a particular payer. CMS does not require that MMPs adjudicate each individual claim against separate coverage rules.

6 MMP contracts stipulate that MMPs submit Encounter data for medicare and Medicaid institutional services (837I), professional services (837P), DME (837P DME), Medicaid Dental services (837D), and Medicaid additional drugs (NCPDP PA ) to CMS at least monthly. MMPs (or their third party submitter) may choose to submit more frequently. Q5: What are the capitation quality withhold requirements related to MMP Encounter data Submission ? A: CMS withholds a portion of the monthly medicare and Medicaid capitation rates pending MMPs meeting certain performance metrics. These include meeting the Encounter data Submission requirements regarding frequency ( , at least monthly Submission of each required file per Q7 below) and timeliness ( , within 180 days of the ending date of a given service).

7 For details on quality withhold, please see the criteria in the Capitated Financial Alignment Model Quality Withhold Technical Notes for each Demonstration Year, available at: Q6: What are CMS criteria for successful MMP Submission of Encounter data for purposes of quality withhold? A: CMS has two main criteria: frequency and timeliness (a third start date is applicable only to new plans). Additional details on the two criteria are below. 2 Please see HPMS Memo Preliminary Guidance for Encounter Data Reporting for MMPs dated 07/26/13 3 Frequency: Plans submit one of each of the following files to CMS at least once per month (and may choose to submit more frequently) 1.

8 medicare Institutional (837I) 2. medicare Professional (837P) 3. Medicaid Institutional (837I) 4. Medicaid Professional (837P) Timeliness: MMPs submit Encounter data within 180 days from the ending date of service. This applies to all Encounter submitted in the 8 files ( medicare and Medicaid institutional, professional, DME, Medicaid Dental, and Medicaid additional drugs (NCPDP)). We only count original accepted encounters. We do not count chart review encounters, voided, adjustments, or rejected encounters. Please note that states may have additional requirements for Encounter data submitted to them. CMS encourages MMPs to work with their providers to ensure timely Submission of claims.

9 Q7: What if an MMP has no encounters to report for the frequency criteria? A: CMS will not penalize MMPs that have no encounters to report for a given month in one of the files noted above, , since the previous month s Submission , providers did not submit any new encounters and/or the MMP s Encounter system has not fully processed new encounters. When CMS reaches out with the results of the quality withhold criteria for a given year, an MMP can certify in the attestation period that they don t have any encounters to submit in a particular file/month. Q8: How do Encounter Submission requirements for MMPs differ from those of medicare Advantage? A: The frequency requirements are unique to MMPs; there are none for medicare Advantage plans.

10 MMPs must submit one of each of the 8 files monthly. The timeliness requirements also differ: For MMPs, we calculate the percentage of encounters submitted within 180 days of the end date of service. For medicare Advantage, there isn t a timeliness deadline for the Submission of Encounter data records. Q9: What are the Submission requirements for Part D Drug Events and Risk Adjustment Process Systems? A: Part D Drug Events (PDEs) and Risk Adjustment Process Systems (RAPS) submissions for MMPs are the same as the existing medicare requirement as documented on the CSSC Operations website (under the corresponding tabs) and do not fall under separate demonstration Q10: Are Encounter submissions required for Risk Adjustment Process System records?